Promoting the healthy development of
your grandbaby’s back and neck

By Esther Gokhale

World-renowned back pain expert and posture guru Esther Gokhale is founder of the Gokhale Method Institute and author of the award-winning book 8 Steps to a Pain-Free Back. We recently asked Esther a number of questions pertaining to the neck and back health of children during the first few years of life.

What is the best way to carry and hold an infant, baby, or toddler?

If you observe almost any 1-year-old or 2-year-old, you will see Primal Posture in action. When seated on the floor, babies automatically sit right on their sitting bones without slumping or slouching — with “anteversion” spine — that is, not tucked under, but rather, slightly tipped forward. From this foundation, babies exhibit straight spines from the low back right up through their necks, so the head is beautifully balanced. Because babies do this naturally when they are ready to sit up unaided, there is no strain and the head does not have to be “held up.” So, as baby becomes able to sit on her own, let her sit on your forearm with her pelvis tipped forward. Notice that her spine will naturally stack up without any difficulty.

As for carrying babies for longer periods, I have observed that in most parts of Africa, where back/neck pain is rare, babies are wrapped onto their mothers’ backs, held tightly with fabric. Their bottoms are supported, and their backs are stretched in a lengthened position. To help promote a long and healthy spine with proper pelvic positioning, ideally, you would carry your baby on your body as much as possible. However, in industrialized societies, the parent’s or grandparent’s own structure often can’t sustain that degree of load comfortably, or it simply feels too unconventional. In that case, it is important to know what to look for in a baby sling or stroller.

Please describe the differences between a J spine, C spine, and S spine as well as what you mean by “ducky butt, not tucky butt.”

The J spine is the natural shape we observe in infants. In a J spine, the pelvis is slightly anteverted at the lumbar-sacral junction. It literally puts the behind behind, which is why it resembles a “ducky butt.” This position allows the bones of the spine to stack vertically, which is the ideal posture for back/neck development and long-term back/neck health. In a C spine, the pelvis goes the other way and tucks under — hence, “tucky butt.” A tucked-under pelvis will usually put the spine into a curved, slouched-over C shape. The S spine is now so common in our society that it is regarded as normal, but it actually involves some degree of sway back — that is, over-contraction in the lumbar area — and a corresponding rounding forward in the upper back and/or neck.

How do most Americans carry and hold their infants, babies, and toddlers?

How are we to know how best to carry and hold our infants? Children don’t come with a care manual! What worked for thousands of years was that everyone, including older siblings, adopted the traditional body wisdom from role models all around them.

Since the Industrial Revolution, families have become more geographically dispersed, with parents raising their children many miles away from grandparents and other extended family. This has led to a break in cultural transmission and in the handing down of tried and tested kinesthetic traditions.

Unfortunately, we now unwittingly undermine the instincts that our infants are born with because our misconceptions about human form inform the way we carry our young. For example, because we think it is normal to tuck the pelvis, you see babies held with the parent’s forearm tucking baby’s bottom under — which prevents her from stacking her spine on her own. Don’t scoop that pelvis back!

Another common misunderstanding is that when feeding and resting their babies, parents often cradle their infants in a fetal curve, whereby the infant’s spine will hang in a C shape. It is far better to provide the support of a bent leg or cushion so the spine can enjoy healthy length.

What are the risks of carrying/holding a baby improperly, both to the child and the person carrying the child? And what are the potential benefits of carrying/holding a child properly?

During the early formative years, the neural pathways are developing. The child’s brain, muscles, and bones are constantly developing and learning what constitutes head control, crawling, sitting, standing, and so forth. Most, if not all, models of childhood development propose that getting these foundations wrong will cause problems later on. For example, if an infant is constantly propped up before he is ready to sit, he will probably slump forward, tucking his pelvis and collapsing into his chest.

Pay attention to your own posture as well! So many new parents and grandparents complain of avoidable back, shoulder, and neck pain. Keep your shoulders rolled back when holding your baby or grandbaby. Hold your toddler off to your side or slightly to the back rather than right in front of you. This helps distribute his weight closer to your spine, which is preferable. When picking up a baby, get very close so as not to let your shoulders and upper back slip forward. As she gets heavier, tighten your abdominal muscles as you bend from the groin while maintaining an elongated spine. We are probably more vulnerable to injury when stressed or tired, so new parents coping with interrupted sleep or grandparents who tire more quickly can especially benefit from practicing good form.

At the Gokhale Method Institute we are seeing an increasing number of parents with RSI (repetitive strain injury) conditions, such as tendonitis. To avoid RSI, try to use your forearms rather than your hands to grip the child, so your larger arm muscles rather than your weaker forearm muscles support the child’s weight. Simple measures like the shoulder rolls we teach in our free workshops (in various locations around the country and online), performed easily and frequently, will also help to keep good circulation throughout the upper limbs and to preserve the necessary space to avoid impingement of the nerves.

Which types of slings and other devices do you recommend and which do you discourage?

To carry an infant on your front, you can use a sling like the ones made by Girasol, which works better than most front packs.

The criteria in choosing a particular brand of sling are:

How close is the baby to your body? The closer, the better for both the baby and you.

Does the sling respect the natural J-shape you want to cultivate in the baby? Ideally, you would like to habituate your child or grandchild to an elongated spine with his behind out behind.

If the sling does curve the baby’s spine some, are you keeping pressure off his lower back (so the baby is reclined to some extent)? It is also important to balance the time the baby spends in the sling with time spent getting some gentle stretch in his torso.

If you are looking for a modern carrier for a baby or toddler, find one in which the child’s bottom has space to remain behind her (the Ergobaby is preferable to Baby Bjorn, for example) and her legs are encouraged to turn out. Allowing her legs to externally rotate in this way allows her immature hip sockets to ossify in a healthy way rather than setting her up to have knock-knees and fallen arches.

You’ve said that many baby carriers, car seats, baby swings, walkers, jumpers, strollers, and the like are “setting kids up to slump.” How so? And why is that detrimental?

Many modern baby carriers and other contraptions on the market today are molded in a C shape, which will be the position recreated in the baby’s spine. This curve will collapse a baby’s spine, tuck the pelvis under, and bend her neck forward. If you look at most strollers, baby carriers, and car seats, they are almost all shaped this way. In addition to forcing baby to sit poorly while in the contraption, consider that infants are often in these implements for hour after hour, sometimes confined to them from the house to the car, while in the car, while in the store or park or other location, then out of the car and back into the house. That is why these products are probably the chief culprits in breeding familiarity with the poor sitting patterns that set kids up for slouching.

If you use a stroller for infants, find one that is completely flat so the baby can stretch out on his back. Many strollers have infant attachments that allow for this, and they look similar to old-fashioned pram strollers. Try and avoid the strollers where you just click in the car seat.

As the child grows and can sit upright, find a stroller and car seat with a 90-degree angled seat. Avoid soft seat pans (like in umbrella strollers) that encourage the C-shape and the child’s legs to rotate internally. You want to give the child room to scoot her rear-end back and then stack the spine long, just like she naturally sits. Sometimes, you can help this along with cushions or padding.

What kind of, if any, child seats do you recommend? Do you recommend any alternatives to these types of seats?

Almost all infant car seats are slightly curved, and for safety reasons, you may not be able to avoid them, nor is it advisable to modify them. Try to minimize the time your baby spends in car seats, and of course, leave the seat in the car rather than toting your little one around in a compromised position. For older infants, you can use strategically placed folded towels, for example, to help them from tucking the pelvis and slouching forward.

Can you offer any advice for carrying and holding newborns?

Let your infant stretch long as often as possible when holding her, rather than curling her up into a fetal position. Support your baby’s head for as long as necessary, with a view to maintaining her neck and the back of her head in line with her spine, as when she is lying on her back on a flat mattress. When your baby has more head control, you can hold her on your hip and wrap your forearm around her mid-back, giving her a gentle stretch in her back.

When breastfeeding or bottle-feeding, bring the baby to you, with your shoulders back and relaxed and your spine straight so you are not stressing your own back into a rounded, C-shaped position. Try to stretch her spine gently while she is nursing or suckling. A wooden rocking chair that allows you to sit upright with your head supported as you lean back is very comfortable. However, even on a soft couch or chair, deliberately keep your bottom behind you as you sit down to maintain your own anteverted pelvis.

When is it wise to start standing an infant on her/his legs with your support?

We do not advocate supporting a child to stand for significant periods until he has shown his own readiness to pull himself up and stand on his feet. As your baby begins to walk, he will have an innate reflex that allows his feet to play an active part in this new skill. This grab reflex remains in place for the first 20 months of life. The ability to shorten his foot by using his arches and foot muscles will give him the power and control to move forward in balance. If shoes are put on babies’ and toddlers’ feet, this foot coordination can become inhibited or lost altogether. Whenever possible, let your toddler walk barefoot. If the floor is cold, find flexible socks / slippers that have some sticky tread on the bottom. Better yet, let your baby work his feet in sand, soil, and contoured surfaces when crawling to build up his foot action in walking.

One thing to mention here is that the synchronization of arm and leg movement in crawling is instrumental in proper gait development, so it is important not to bypass this stage by putting babies in any type of “walker.” These contraptions may also encourage infants to feel the ground from a slumped, semi-seated position, which completely interferes with their natural ability to find their balance by aligning their body weight perfectly over the heel bone.

How else might we teach and encourage proper posture to babies and toddlers?

If a child is fortunate enough to be handled well and has good furniture, chances are he will do what comes naturally and no teaching will be necessary. He may well even choose to stack well, rather than slouch, when perched on the edge of a bad chair. Kids who have been less fortunate will often need help, but avoid the clichéd calls to “stand up straight” and to “keep your chin up and chest out.” Both can lead to further problems because they don’t get the response we want. Instead, use fun and child-friendly cues such as “Have a ducky butt, not a tucky butt,” and “Imagine you have a tail. It should be out behind you. You don’t want to be sitting on it.”

Providing a posture-friendly environment as your child grows can help her retain her natural J-shape posture into her toddler and school-age years. Notice her positions. When reading books or playing, let your child sit on the floor. If you catch her slumping and tucking her pelvis, gently reposition her body. It will not be difficult when she is very young. Try and avoid the squishy overstuffed armchairs, as children will often begin to slump, much like adults do. Simple 90-degree–angle chairs with room for the bottom to go back and room for the shoulders to roll back are preferable. High chairs and booster seats should resemble this shape as well. Stokke® chairs work well for use at the table.

If your child likes to sit on a pillow, encourage him to sit on the edge of the pillow to help keep his pelvis anteverted (tipped forward). A pillow on the floor or near the back of a chair is great, as it acts as a little wedge to encourage the pelvis to tip forward.

Ultimately, our children will look to us to set the example. If we are slouching on our couches, chances are they will eventually, as well. Invest in learning how to improve your own posture. You will not only create a better model for your children and grandchildren, you will also signal to them the importance of this forgotten pillar of health.

Editor’s Note: For more information on grandchildren health click here.